Status epilepticus has been defined as a condition in which "epileptic activity persists for 30 minutes or more, causing a wide spectrum of clinical symptoms, ...".167
Emergency treatment should be sought or given by carers of people with epilepsy once a seizure has persisted, or there are serial seizures, for more than five minutes. Ceneralised tonic-clonic status epilepticus is a medical emergency with significant morbidity and mortality, which can often be attributed to inadequate or delayed treatment.168-170 Other types of status epilepticus (including simple partial, complex partial and absence status epilepticus) are often associated with delayed diagnosis and treatment, but have a much lower risk of morbidity. Prompt and accurate differentiation of status epilepticus from pseudo-status epilepticus and other non-epileptic disorders is crucial if inappropriate treatment and iatrogenic morbidity are to be avoided.168,171 EEG recording may be necessary to confirm the diagnosis and to assess control, when seizures are clinically subtle (eg in partial status, or following treatment of tonic-clonic status epilepticus).172
Recommendations for treatment are based on two large prospective, randomised trials of the management of status epilepticus173,174 and on small or uncontrolled studies, physiological principles and pharmacokinetic considerations.167,175-180 Intravenous lorazepam and diazepam are both effective and safe in controlling tonic-clonic status epilepticus, when administered by paramedics, prior to transport to hospital, with a trend in favour of lorazepam.173 Intravenous lorazepam, phenobarbital and diazepam plus phenytoin are all effective initial treatments on hospital admission, with a trend again in favour of lorazepam, which is significantly more effective than phenytoin alone.174 Lorazepam has the advantage over diazepam of a much longer duration of action, but its use in the community is limited by the need for refrigerated storage. There should be a high level of awareness of the risk of respiratory depression. Additional maintenance treatment is required following initial use of either benzodiazepine. Fosphenytoin is less irritant to veins than phenytoin and can be administered more rapidly (but still needs to be given slowly).
In the community or in hospital, patients with generalised tonic-clonic status epilepticus should be managed immediately as follows (with local protocols being in place):
■ secure airway
■ assess cardiac and respiratory function
■ secure IV access in large veins.
Give lorazepam 4mg IV or diazepam 10 mg IV if lorazepam is unavailable. This can be repeated in hospital after 10 minutes if there is no response. If there is a delay in gaining IV access in the community: give diazepam 10-20mg rectally (rectal solution or IV solution).
■ collect blood for full blood count, urea and electrolyte, liver function tests, calcium, glucose, clotting, AED levels and storage for later analyses
■ measure blood gases to assess extent of acidosis
■ establish aetiology. Give 50ml 50% glucose IV if there is any suggestion of hypoglycaemia and IV thiamine (given as Pabrinex two pairs of ampoules) if there is any suggestion of alcohol abuse or impaired nutritional status.
WITHIN 30 MINUTES
For sustained control in patients with established epilepsy, within 30 minutes:
■ give usual AED treatment orally or by nasogastric tube (or IV if necessary for phenytoin, sodium valproate and phenobarbital).
For sustained control in other patients or if seizures continue, within 30 minutes:
■ give fosphenytoin in a dose of 18mg/kg phenytoin equivalent (PE) IV, up to 150mg/ min with ECG monitoring; or phenytoin 18mg/kg IV, 50mg/min with ECG monitoring or phenobarbital 15mg/kg IV, 100mg/min. Rates of infusion may need to be reduced if hypotension or arrythmia occur or in elderley or renal/ hepatic impairment.
0 Clear policies should be in place to avoid confusion between doses, formulations, routes and rates of administration of fosphenytoin and phenytoin.
If status epilepticus persists the patient needs to be admitted to an intensive treatment unit (ITU) and anaesthetised with EEG monitoring. Midazolam, pentobarbital (unlicensed), propofol or thiopentone are most commonly used in these circumstances.180
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